There are large variations in Medicare spending and utilization (healthcare intensity) across the United States. Such regional differences in intensity of care are not explained completely by patient case mix or patient preferences. Furthermore, outcomes, quality of care and patient satisfaction appear to be similar or worse in regions with the highest compared with lowest intensity of care. These findings have been interpreted to suggest that efforts to reduce spending in high intensity regions may be undertaken without compromising quality of care. However, high spending regions differ in other important respects from low spending regions. They are disproportionately urban, and include a disproportionately large percentage of minority groups. In considering the impact of policies to reduce spending and utilization in high intensity regions, it may be important to evaluate the extent to which there are currently racial- ethnic disparities in access to and quality of care in high and low intensity regions. This information may be important in shaping future interventions to address Medicare utilization and spending in these regions. To date, the relationship between regional differences in healthcare spending and health care disparities has not been studied in depth. The applicant proposes to evaluate this relationship among patients with end- stage renal disease-a disease that disproportionately impacts minority groups and for which there are known racial-ethnic disparities in care. We will systematically evaluate racial ethnic disparities during several distinct phases of care including prior to initiation of ESRD, during treatment for ESRD and at the end of life prior to death. We propose the following specific aims: 1) to evaluate the relationship between regional variation in healthcare intensity and racial disparities in access to preparatory measures for initiation of dialysis and preemptive transplantation 2) to evaluate the relationship between regional variation in healthcare intensity and racial disparities in quality of care measure for dialysis and transplantation 3) to evaluate the relationship between regional variation in healthcare intensity and racial disparities in end-of-life quality measures for terminally ill patients receiving dialysis. We anticipate that the proposed study will provide a comprehensive description of regional variation in healthcare intensity and disparities for minority populations with end-stage renal disease. Our findings may be helpful in raising awareness of the potential impact on racial-ethnic disparities in access to a quality of care of future health policy interventions to reduce spending in high intensity regions. PUBLIC HEALTH RELEVANCE: Recent research into Medicare spending patterns has identified significant regional variation across the US in Medicare spending and utilization among otherwise similar patients. These spending patterns don't seem to correlate with better patient outcomes or provider satisfaction. Some have interpreted these findings to suggest the possibility that spending may be reduced in higher spending regions without compromising quality. However, the implications of targeting high spending regions in efforts to reduce costs and utilization have not been fully explored. In particular, these high spending regions tend to be disproportionately urban and home to a disproportionately large proportion of minority patients. Thus, it may be important to evaluate the extent to which access and quality of care in high spending regions is equitable for patients of different racial ethnic groups. If disparities in access to and quality of care among racial-ethnic groups are less favorable in high spending regions, it may be important to evaluate future policy changes in the context of such disparities. We propose to evaluate health disparities across regions with different patterns of Medicare spending for end-stage renal disease (ESRD) a disease that disproportionately impacts racial ethnic minority groups and for which there are known disparities in many aspects of care, including kidney transplant and nephrology referral.